Note: If the Annual Report is executed by an authorized representative, a board resolution evidencing
such authority must be submitted.

Name of the Enterprise
Name of the Chief
Executive Officer/President
Name of Authorized
Representative
Office Address
Plant Location
Telephone Number
Email Address
Authorized Product/
Activity
Equity Investments
Foreign
Local

__________________________
Signature over Printed Name
__________________________
Position

Republic of the Philippines
City of ________________
Subscribed and sworn to before me, this _____ day of ______ , _________________
exhibited to me his/her ___________ ID, numbered ________, issued on ____________ in
______________.
Notary Public